Implementing psychological care in emergency departments for suicide prevention

Table 2 Implementation barriers and evidence-based solutions for emergency department suicide prevention programs

Barrier category	Specific barriers	Evidence-based solutions	Supporting evidence
Workforce and training	Limited mental health specialists in ED; inadequate suicide risk assessment training; high staff turnover	Task-shifting with protocolized interventions; standardized training programs; telehealth consultation models	Nurse-led SPI implementation[20]; ED-SAFE training protocols[11]; SPCC telehealth model[40]
Workflow and resources	Time constraints; competing clinical priorities; lack of dedicated space for interventions	Integration into nursing discharge process; electronic health record prompts; dedicated “suicide prevention coordinator” role	SPI embedded in discharge workflow[29]; EHR clinical decision support[36]; follow-up coordinator models[45]
Assessment and documentation	Inconsistent risk assessment; lack of standardized tools; poor documentation	Mandatory use of validated tools (Columbia-Suicide Severity Rating Scale); structured documentation templates; automated risk scoring	Columbia-Suicide Severity Rating Scale validation in ED settings[44]; standardized assessment protocols[11]
Care coordination	Fragmented post-ED care; poor communication with outpatient providers; lost to follow-up	Warm hand-offs; shared EHR alerts; fixed appointment timelines (≤ 7 days); centralized follow-up systems	Integrated care pathways[49]; formal community partnerships[12]; systematic contact protocols[31]
Cultural and systemic	Stigma; organizational resistance; lack of leadership support; funding constraints	Implementation science frameworks (RE-AIM, CFIR); leadership engagement; quality improvement initiatives	Zero suicide framework implementation[36]; organizational readiness assessment[13]
Technology and access	Digital divide; privacy concerns; interoperability issues	Hybrid models (in-person + digital); app-based safety planning; telehealth follow-up	Digital DBT interventions[15]; SPI apps[23]; telehealth service models[40]

ED: Emergency department; SPI: Safety planning intervention; SAFE: Suicide assessment follow-up and engagement; SPCC: Suicide Prevention and Crisis Center; HER: Electronic health record; RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance; CFIR: Consolidated Framework for Implementation Research; DBT: Dialectical behavior therapy.